Nokea
Which nursing action is best for controlling the client's nosebleed?
- A. Have the client lie down slowly and swallow frequently.
- B. Have the client lie down and breathe through the mouth.
- C. Have the client lean forward and apply direct pressure to the nose.
- D. Have the client lean forward and clench the teeth.
Correct Answer: C
Rationale: Leaning forward and pinching the nose controls bleeding effectively.
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The client is diagnosed with a viral infection and the HCP has prescribed an antiviral medication to be administered by weight. The client weighs 220 pounds and the order reads 10 mg per kilogram per day to be administered in equally divided doses every six (6) hours. How many milligrams will be administered in one dose?
Correct Answer: 250
Rationale: 220 lbs ÷ 2.2 = 100 kg; 10 mg/kg/day = 1000 mg/day; 1000 mg ÷ 4 doses = 250 mg/dose.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
- A. The client is complaining of severe pain.
- B. The client’s pulse oximeter reading is 95%.
- C. The client has T 100.4°F, P 100, R 24, and BP 102/60.
- D. The client’s urinary output is 50 mL in two (2) hours.
Correct Answer: C
Rationale: Fever, tachycardia, and hypotension suggest sepsis or hypovolemia, requiring immediate HCP notification. Pain is expected, 95% SpO2 is acceptable, and low urine output is secondary.
When assessing the client's skin the nurse notices a rounded area of hair loss with redness, pustules, and scales that appear greenish-yellow when exposed to a black light (Wood's lamp). The nurse should plan to implement treatment for which condition?
- A. Lyme disease
- B. Fungal infection
- C. Anaerobic infection
- D. Contact dermatitis
Correct Answer: B
Rationale: A fungal infection that manifests on the scalp with red, scaly lesions and hair loss will appear either greenish-yellow or bluish-green under a Wood's lamp. Lyme disease produces a bull's-eye rash that does not fluoresce. Anaerobic infections have diffuse redness and do not fluoresce. Contact dermatitis does not display a discrete, rounded area of hair loss or fluoresce.
If a client who has recently experienced diminished hearing takes medications from each of the following drug categories, which one is most likely to have affected the client's hearing?
- A. Nonsteroidal anti-inflammatory drug
- B. Beta-adrenergic blocker
- C. Aminoglycoside antibiotic
- D. Histamine-2 (H2) antagonist
Correct Answer: C
Rationale: Aminoglycosides are ototoxic and can cause hearing loss.
The nurse is preparing the plan of care for a client diagnosed with Stevens-Johnson syndrome. Which interventions should the nurse include? Select all that apply.
- A. Monitor intake and output every eight (8) hours.
- B. Assess breath sounds and rate every four (4) hours.
- C. Assess vesicles, erosions, and crusts frequently.
- D. Perform the whisper test for auditory changes daily.
- E. Assess orientation to person, place, and time every shift.
Correct Answer: A,B,C,E
Rationale: Monitoring I&O, breath sounds, skin lesions, and orientation address SJS complications (fluid loss, respiratory issues, skin breakdown, neurological changes). Whisper test is irrelevant.